How Do You Manage Menopause

Menopause can be one of the most frustrating times for women and treating the symptoms is one of the biggest challenges for physicians. So how do you determine what is best for you? The goal of this article is to provide a starting place to discuss menopause and treatment options with your provider.

When women here the word menopause, most think of hot flashes, night sweats and vaginal dryness. Menopause is the permanent cessation of menses due to the loss of ovarian activity. It is determined to have occurred after 12 months after last menstrual cycle. The average age of menopause is 51 years, however most women begin the transition years before. During this time hormone levels, mainly estrogen and progesterone, fluctuate.

The most common complaints during perimenopause are hot flashes, night sweats (or vasomotor) and vaginal dryness. The sudden sensation of extreme heat in face, neck and chest is known as a hot flush. Episodes can last 1-5 minutes and may be accompanied by sweating, chills, and anxiety. The cause of vasomotor symptoms appears to be multifactorial, with changes in reproductive hormones playing the major role. Vaginal dryness or vaginal atrophy is directly related to loss of estrogen. Loss of estrogen leads to decrease in elasticity (or adaptability) of the vaginal mucosa and narrowing of the vagina. This leads to dryness, pain and vaginal bleeding, impairing sexual function.

The most common question in regards to treating menopausal symptoms is what options are there and are they safe? There are several treatment options for vasomotor symptoms, a brief outline follows:

Hormone Replacement Therapy HRT is the use of estrogen or estrogen and progesterone to reduce the occurrence of vasomotor symptoms. The WHI (Women’s Health Study) was a large study of women from ages 50-77 years. The goal of the study was to determine risk on heart health. The study found that in women taking estrogen alone there was benefit of treating vasomotor symptoms with increase in blood clots. However, there was found to be NO increase risk in breast cancer or heart disease. The women taking estrogen and progesterone had the same benefit for vasomotor symptoms and risks, however, they also had increase risk of breast cancer. The women in this study were menopausal for several years before receiving HRT, therefore it is difficult to determine the risk on younger women taking HRT in the perimenopausal time. The goal of HRT is to use the smallest dose for the shortest time. Likewise, studies have shown that the topical route is best in decreasing risk for blood clots.

Progestin Progesterone is primarily used as an add on agent to estrogen therapy to protect the uterine lining in women who have a uterus. Because of the risk of breast cancer in the combined use group in the WHI study, progestin is not considered a first line therapy.

Testosterone Testosterone for the treatment of vasomotor symptoms has shown no benefit and potential adverse effects such as excessive hair growth, acne and elevated cholesterol.

Bioidentical Hormones BHRT is treatment that uses natural hormones that are equivalent chemically to certain hormones that have been lost with age. Currently estrogen and progesterone are the most common BHRT used. BHRT can be custom-made for and individual, but most are not done this way. The common misconception is that “natural” hormones have no chemical processing and are the same as your own hormones. BHRT are produced using raw materials derived from plants and processed into hormones. Therefore, they are chemically manufactured and are similar to synthetic hormones, except they are not regulated by the FDA for safety. Thus there is a concern for over or underdosing due to variable activity of the compounds. Thus, BHRT should be used with caution and conventional HRT is preferred.

Non hormonal options There are several nonhormonal options for treatment of vasomotor symptoms. Some antidepressants, such as paroxetine, have been effective in nondepressed wormen. Side effects include nausea, dry mouth, fatigue and sexual dysfunction. This may be a option for women who can not use hormones and have more mood symptoms. Other options include clonidine and gabapentin, neither of which are approved by the FDA for this use. Supportive measures such as avoiding caffeine and alcohol, wearing layered clothing, and lowering the ambient temperature may help. Likewise, herbal treatments such as red clover extract and black cohosh have been shown to aid in symptom management.

In regards to treatment of vaginal dryness, there are several options as well.

Estogen Estrogen therapy is effective in alleviating symptoms of vaginal dryness and atrophy. Local therapy is recommended for women who have vaginal symptoms only. Local therapy is available as cream, ring and tablet forms. There is a theoretic concern that the body may absorb local estrogen and increase of endometrial cancer in women with a uterus. However, studies have not proven this, but progesterone therapy may be added. There is also a concern for use in women with history of breast cancer. Thus, nonhormonal methods should be first line in women with hormone sensitive breast cancer.

Ospemifene Ospemifene is a newer medication which works to stimulate estrogen receptors in the vagina but not the endometrium. It has been shown to improve vaginal dryness in postmenopausal women. Common side effects included hot flashes, muscle spasm and sweating. It may also increase risk for blood clots.

Vaginal Lubricants Non estrogen water-based or silicone-based vaginal lubricants and moisturizers many alleviate vaginal symptoms. Lubricants are best used to relieve friction and pain of vaginal dryness with intercourse. Moisturizers are intended to trap moisture and provide long term relief. There is limited data regarding effectiveness, but many women find them to be effective.The menopausal transition can be a difficult time for many women. It may last a 1-2 years or 10-15 years depending on the woman. Thus, it can be challenging to treat the symptoms, as no two women are the same. Women should seek consultation from their healthcare providers for the best treatment options for them.

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